Case Description
A 36-year-old African American female with history of systemic sclerosis
and refractory GERD status post RYGB presented to her primary care
provider with complaints of daily nausea, non-bloody emesis, dysphagia,
and abdominal pain refractory to all medical therapy. Patient had
undergone endoscopic evaluation multiple times for this complaint
initially limited to the gastric pouch secondary to surgical anatomy
with no abnormalities noted. Laboratory analysis was notable for normal
CBC, CMP, negative serologic and stool Helicobacter pylori antigen
testing. The patient was referred back to gastroenterology for repeat
upper endoscopic evaluation. The gastric pouch was notable for diffuse
edema, punctate erythema, and friability (Figure 1) . Biopsies
demonstrating chronic gastritis with extra-nodal marginal zone lymphoma
of MALT type (Figure 2, 3) . A single balloon enteroscopy was
then performed for evaluation with biopsies obtained of the gastric
remnant. Similar gross findings were seen in the gastric remnant,
however, biopsies showed dense lymphoid infiltrate consistent with MALT
lymphoma. All biopsies were negative for H. pylori by
immunohistochemical stains. Previous biopsies prior to RYGB surgery were
reviewed and confirmed to be negative for H pylori infection as were
serologic and stool antigen tests.
The patient was diagnosed with H pylori negative gastric MALT lymphoma,
Lugano stage I, Ann Arbor IE. The case was discussed with a
multi-disciplinary team including medical and radiation oncology. After
discussion with the patient, the decision was made to treat with
rituximab given the risk of large field radiation and her underlying
systemic sclerosis. Repeat endoscopy with biopsy after 4 weeks of
treatment showed no appreciable gross or histologic changes. Having
failed immunosuppressant therapy, patient was initiated on radiation
therapy for a total dose of 30 Gy. On follow up symptoms had improved;
repeat single balloon enteroscopy showed mucosal improvement. Biopsies
were notable for focal atypical lymphoid infiltrate with monocytoid
cytomorphology and focal lymphoepithelial lesion formation, compatible
with focal, residual marginal zone lymphoma (partial histologic
regression). The amount of atypical lymphoid infiltrate was too small
for further assessment by immunohistochemistry. Repeat endoscopy was
planned within the next three months but unfortunately with the advent
of COVID patient was lost to follow up.